A prospective longitudinal cohort study was designed and conducted in the Departments of General Medicine and Radiodiagnosis in MKCG Medical College and Hospital, Berhampur, Odisha, India, over a period of two years from August 2017 to September 2019. The study was conducted after the study protocol was approved by the Institutional Ethics Committee (No 536/Chairman-IEC, MKCG Medical College, Brahmapur, Odisha, India). Informed consent was obtained from all the patients and study was done in accordance with the guidelines of the Declaration of Helsinki 2008.

A detailed medical history and clinical examination were obtained from each patient. A total number of 54 (49 treatment naive+5 from ART centre) patients, diagnosed as HIV positive confirmed by positive ELISA test, belonging to the age group of 18-70 years of both genders, admitted to different wards of Medicine Department or patients attending ART centre of the hospital for routine clinical check up were taken for the study who fulfilled the inclusion exclusion criteria.

Inclusion criteria: HIV infected patients naive to cART and HIV infected patients on cART for a minimum period of three months were included in this study.

Exclusion criteria: Patients known to have Acute Kidney Injury (AKI) or CKD, diabetes mellitus, hypertension, pregnancy, Hepatitis B surface Antigen (HBsAg) positive, Hepatitis C Virus antibody (HCV Ab) positive and patients taking nephrotic drugs were excluded from the study.

All the 49 treatment naive patients were investigated with routine and specific laboratory tests including baseline investigations like Complete Blood Count (CBC), fasting plasma glucose, post prandial plasma glucose, glycated haemoglobin, lipid profile, liver function test, serum urea, serum creatinine, serum electrolytes, serum calcium, serum potassium, serum phosphorous, CD4+ T cell count, HBsAg, HCV Ab, urine for routine and microscopy, urine for microalbumin, Electrocardiogram (ECG) and chest X-ray. Ultrasonography of abdomen was done in the Department of Radiodiagnosis to see the kidney size, Corticomedullary Differentiation (CMD) and thus to rule out CKD and later to assess HIV Associated Nephropathy (HIVAN) with the findings of enlarged, echogenic kidneys. Height, weight, pulse, Blood Pressure (BP) and Body Mass Index (BMI) of all the patients were recorded. Five patients who met the clinical and laboratory criteria were also included in this study from the ART centre of the hospital after verification and review of the records. The same investigation reports were collected when they were treatment naïve.

Out of 54 HIV positive patients, 42 patients were treated with triple therapy regimen of tenofovir disoproxil fumarate 300 mg+lamivudine 150 mg+efavirenz 600 mg (TDF+3TC+EFV) and 12 patients were treated with zidovudine 300 mg+lamivudine 150 mg+nevirapine 200 mg (AZT+3TC+NVP). All patients were selected randomly and took the drug regimen at bedtime. All the investigations were repeated after six months of treatment on cART. As present cohort was a prospective study with internal comparisons, renal functions of 54 (49+5 from ART centre) treatment naive patients were compared with the renal functions of the same 54 patients after six months on cART/HAART.

A pilot study was conducted in the ART centre in the hospital, where records of eight HIV positive patients on HAART were verified. Percent of exposed with outcome was found to be 25 with an improvement in renal parameters in two patients after six months on HAART.

Sample size calculation: The sample size was calculated by using an online sample size calculator (Open Epi version 3.01) and assuming percentage of exposed with outcome to be 25%, at 5% precision and 95% level of confidence interval. The minimum required sample size was calculated to be 51 in each group.

Creatinine Clearane (CrCl) was calculated from the patients age, sex and serum creatinine according to the formula derived from Cockroft-Gault equation [9,10]:

CrCl={140-age (years)}×weight in kg/serum creatinine×72 (male).

CrCl={140-age (years)}×weight in kg×0.85/serum creatinine×72 (female).

GFR was estimated from serum creatinine according to the study equation of MDRD [11].

GFR=186×(SCr-1.154)×(Age-0.203)×{(0.742) if female} and {(1.210) if black/male}.

This MDRD study equation calculator is for use with SCr reported in mg/dL. Hepatitis B (HBsAg), Hepatitis C (HCV Ab) serology tests was done using Enzyme-Immuno Assay (EIA) kits. CD4+ T cell count were determined by Fluorescence-Activated Cell Sorting (FACS) count version 1.00/08 medicine.

Data were entered using Microsoft Excel and exported to SPSS version 17.0. Comparison of parameters was done using Analysis of Variance (ANOVA) and correlations between parameters were analysed using Pearson correlation analysis. Values were expressed as mean±SD/or proportion (percentage) with statistical significance set at p-value less than 0.05 (p<0.05) were considered statistically significant.

A total number of 54 HIV positive patients were included in the study, out of which 29 (53.7%) were males and 25 (46.3%) were females, of age ranges between 18-70 years with mean age of 39.83±10.73 years [Table/Fig-1].

The mean BMI in study was (18.827±4.593 kg/m²). The mean of CD4+ cell count of HIV positive treatment naive patients and on Highly Active Antiretroviral Therapy (HAART) was higher and was very highly significant (p=0.001) [Table/Fig-2].

The mean serum creatinine of HIV positive patients on HAART (0.815±0.1393 mg/dL) was lower than HIV positive treatment naïve patients (0.906±0.1687 mg/dL) and was also significant (p=0.003) [Table/Fig-3].

There was a positive and non-significant correlation of eGFR with BMI. There was a positive and non-significant correlation of eGFR with CD4+ count [Table/Fig-4].

There was a positive and significant correlation of CrCl with CD4+ count among treatment naïve patients. There was a negative and non-significant correlation of CrCl with CD4+ count among HIV positive patients on HAART [Table/Fig-5].

There was a negative and non-significant correlation of serum urea of CD4+ count. There was a positive and non-significant correlation of serum urea with CD4+ count among HIV positive patients on HAART [Table/Fig-6].

There were two regimens taken under study for HAART (ZLN) regimen and TLE regimen).

The mean CrCl of HIV positive patients on ZLN regimen was higher than HIV positive treatment naive patients but was non-significant (p-value=0.085). The mean CrCl of HIV positive patients on TLE regimen was higher than HIV positive treatment naïve patients but was non-significant (p-value=0.337) [Table/Fig-7].

The mean eGFR of HIV positive patients on ZLN regimen was higher than HIV positive treatment naïve patients but was non-significant (p=0.088). The mean eGFR of HIV positive patients on TLE regimen was higher than HIV positive treatment naïve patients but was non-significant (p=0.869) [Table/Fig-8].

The percentage of patients with CrCl ≤60 mL/min decreased from after treatment showing improvement in CrCl. Then there was increase in percentage of patients with CrCl in range of 60.01-90 mL/min treatment indicating improvement of patients with CrCl ≤60 mL/min to this range of 60.01-90 mL/min. There was also increase in percentage of patients with CrCl ≥90.01 mL/min after treatment indicating patients improved in CrCl after treatment [Table/Fig-9]. But the change in mean values of CrCl in those three ranges were not statistically significant [Table/Fig-10].

Changes in Radiographic Parameters

All the 54 patients presented with normal CMD and renal thickness. Nephromegaly was observed in 16 (29.6%) treatment naïve patients with mild increase in size, out of them (n=9) were males and (n=7) were females. Hyperechogenic kidneys were found in 47 (87.03%) treatment naïve patients where number of males was 26 and number of females was 21. After three months on cART, no changes were observed. But after six months on cART, all the above patients regained normal size and cortical echogenicity.

The objective of this study was to assess the renal function abnormalities in HIV infected patients and to compare the change in renal function of treatment naïve patients with those on cART. Combination cART, also known as HAART is now recommended in all people with confirmed HIV infection, irrespective of CD4 count or clinical status. Two nucleoside or Nucleotide Reverse Transcriptase Inhibitors (NRTI) together with a Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI), Protease Inhibitor (PI) or integrase inhibitor is standard cART. In the present study, 42 patients were treated with dual NRTI combinations of tenofovir and lamivudine along with one NNRTI efavirenz and 12 patients treated with dual NRTI combinations of zidovudine and lamivudine along with one NNRTI nevirapine. It is now known that there are several renal syndromes and diseases associated with HIV infection [12]. In US African Americans have approximately 3-4 folds higher rates of ESRD compared to European Americans [13]. The prevalence of HIVAN among African Americans was estimated at between 3.5-10% in a primary care setting [14] and at 12% in an autopsy based study from patients treated with HAART [15]. This study shows serum urea of HIV positive patients after six months on HAART was lower 25.78±4.721 mg/dL than HIV positive treatment naïve patients at recruitment baseline 26.19±4.742 mg/dL but was non-significant (p=0.640). Low serum urea in patients on HAART can indicate liver dysfunction. Serum creatinine level was lower (0.815±0.1393 mg/dL) and highly significant (p=0.003) in HIV positive on HAART in comparison to HIV positive treatment naïve patients (0.906±0.1687 mg/dL). The low serum urea and low serum creatinine concentration in HIV positive on HAART patients found in this study is similar to the studies done internationally by Eneyew K et al., in Ethiopia and Emem C et al., in Nigeria [16,17]. These results differ from previous studies where they found high urea concentration with normal serum creatinine [18].

Serum creatinine is inversely proportional to CrCl. This study shows increase in CrCl in patients on HAART (79.09±25.705 mL/min) and highly significant (p=0.003) in comparison to treatment naïve patients (69.65±25.506 mL/min). This was similar to study Kirchner J [19], where benefit of HAART was reported in two African American patients with two NRTI and antiprotease. Lower GFR signifies a true loss of kidney function even if reduced GFR is expected with ageing. It is required to estimate GFR to stage CKD, rather than relying on serum creatinine concentration. This study shows eGFR increased (102.711±26.9424 mL/min/1.73 m²) on HAART and highly significant (p=0.003) in comparison to HIV positive treatment naïve patients (90.189±28.2575 mL/min/1.73 m²). This was similar to an observational prospective multicentre cohort study where GFR was improved regardless of ethnicity, CD4+T cell counts and baseline renal function with or without viral suppression [20]. There was no proteinuria in any patient of both treatment naïve and on HAART.

The primary limitation to the generalisation of these results is; it was a single centre study with a smaller sample size.

This study showed that HIV positive patients on triple drug cART of both the regimens of tenofovir, lamivudine with efavirenz and zidovudine, lamivudine with nevirapine had change in mean renal function and all biochemical and radiological parameters improved after treatment with significant change.